NO.________________________________________Post NO._____________________________________

NAME__________________________________________________________________________________

ADDRESS_______________________________________________________________________________

PHONE________________________________CELL ____________________________________________

DEPARTURE DATE_________________________RETURN DATE_________________________________

TYPE OF PREMISE: RESIDENCE__________________BUSINESS__________________OTHER___________

HAVE KEYS BEEN LEFT WITH ANYONE? YES_____________NO_____________

IF YES, NAME_________________________________ADDRESS_________________________________

PHONE#________________________________________________________________________________

WILL ANYONE BE WORKING OR HAVE ACCESS TO PREMISES DURING YOUR ABSENCE?______________

IF YES, NAME___________________________________________________________________________

IN CASE OF EMERGENCY DO YOU WISH TO BE NOTIFIED BY COLLECT CALL? YES_________NO________

C/O NAME_________________________________ADDRESS____________________________________

PHONE#________________________________________________________________________________

I REQUEST A SECURITY CHECK BE MADE OF MY PREMISES AND AGREE TO NOTIFY YOU OF MY RETURN.

SIGNED_________________________________________DATE OF REQUEST______________________